The Golden Hour for Wounded Warriors
Important strides in providing vehicle and body armor, innovative changes in doctrine, tactics, techniques and procedures, and advances in military medical technology are having profound impacts on survivability but it is the helicopter that is the true lifeline.
By Captain George V. Galdorisi and Scott C. Truver
“Taking care of those wounded in battle is a top priority for me…. The changes and breakthroughs in battlefield medicine have been incredible. It is difficult to predict what these will mean in the future.”
Admiral Michael Mullen
Chairman of the Joint Chiefs of Staff
November 28, 2007—Speech at the Army War College
Chairman of the Joint Chiefs of Staff
November 28, 2007—Speech at the Army War College
Perspective
The need to care for our wounded warriors is compelling. Important strides in providing vehicle and body armor, innovative changes in doctrine, tactics, techniques and procedures, and advances in military medical technology are having profound impacts on how many of our soldiers, sailors, airmen, Marines, and special operations warriors are surviving their wounds.
The continuum of quality medical care to our wounded warriors begins with self- or buddy-aid at the time of injury … to the first time the warrior receives surgical care on the battlefield … to the time when he or she receives either follow-on surgical or rehabilitative care at a higher echelon of care either in-theater or back home in the United States.
But how that wounded troop is transported is increasingly under stress. As the distinction between forward and rear areas increasingly is blurred––as bombings in Baghdad and other cities tragically underscore––and as military medical capability is brought to the wounded warrior to deliver immediate care, the method of reaching or moving that severely injured man or woman often becomes the critical path for survival during the golden hour, that first hour after receiving major, life-threatening trauma.
Past becomes Prologue
Treating wounded warriors on the battlefield is as old as warfare itself. In the beginning there was no organized means of evacuating the wounded from the battlefield and the most seriously wounded were either killed or left to die where they fell. The first organized battlefield evacuation system was fashioned in the Byzantine Empire, with corpsmen stationed 100 meters behind the action and charged with the mission of rescuing the wounded. Significantly, no formal evacuation system existed in Western Europe until the late 18th Century. Since then, the discipline of evacuating and treating wounded warriors has been enshrined in military doctrine.
But it would take the first flight by the Wright Brothers in 1903 to give armies the hope that wounded could be rapidly transported from the fighting directly to a care facility. Advances in medical technology and procedures in the early 20th Century provided the means to treat battlefield wounded with life-threatening injuries if the patient could reach a basic medical facility removed some distance from the fighting. And aviation offered that promise as military medical professionals recognized that survival or death was fundamentally affected by the speed with which the wounded soldier received medical care. In the United States, innovators took on board the lessons of the first World War––the early delivery of first aid, the resuscitation of vital body functions degraded by injury, and the implementation of initial stabilizing surgery were particularly important––and concluded that evacuation of battlefield wounded by airplane offered enormous promise. But, while the interwar years saw experimentation and conjecture, advances were fragmentary and halting.
However, an event in World War II far from the major theaters of the war energized the discipline of aero-medical evacuation of combat wounded perhaps more than any other single innovation. On April 25 and 26, 1944, an Army Air Corps pilot in a Sikorsky YR-4 Hoverfly helicopter lifted four wounded British airmen to safety near Taro in northern Burma. In no time, helicopters took over the role of medical evacuation of combat wounded.
The French used helicopters to evacuate wounded troops during the conflict in Indochina, as did the British in Malaysia. During the Korean conflict, the use of helicopters for combat casualty evacuation blossomed, with UN forces pioneering new methods of helicopter evacuation of wounded troops. This new era of medical evacuation––where air evacuation of wounded troops was typically the only option––was popularized by the familiar title M.A.S.H.
Soon after the Korean armistice, the Army held a design competition to choose a new helicopter ambulance. The winner of the competition, the Bell XH-40 (later to be called the HU-1 Huey) was the first helicopter built to medical department specifications and became the most successful helo ambulance of that era. The use of the Huey for air-evacuation missions in Vietnam, along with organizational and operational changes to battlefield casualty evacuation, generally, reduced the overall risk of dying in combat from wounds to less than one-half that of World War II.
The post-Vietnam area witnessed rapid advances in both military and civilian casualty evacuation helicopters, and by the 1970s air ambulances routinely began to carry physiologic monitoring equipment, defibrillators, IV pumps, sophisticated medical equipment for intubation, suction, drainage, probing and cardiac infarction monitoring. By early 2008, almost any piece of life-saving and life-sustaining equipment short of an MRI has been put into a helicopter, and the promise of an airborne intensive care unit is within reach.
Today’s Battlefield Realities
Operation Desert Storm showed that in spite of the relatively low number of coalition combat wounded and the widespread availability of helicopter support, many that did receive major traumatic injury experienced long delays before they received any surgical care, in some cases up to 24 hours. The fix was soon in coming, as the Army developed the concept of a forward surgical team (FST) while the Marine Corps devised the similarly focused forward resuscitative surgical system (FRSS) teams staffed by Navy personnel.
A highly mobile, rapidly deployable, trauma surgical unit that will provide emergency surgical interventions required to stabilize casualties who might otherwise die or lose limbs before reaching treatment, the FRSS is specifically designed to treat wounded during the golden hour. The FRSS team performs resuscitative surgery, with the objective of decreasing mortality in the potentially savable group of casualties and decreasing morbidity by rapid restoration of normal physiology and control of contamination. However, this resuscitative surgery must be followed up by definitive surgery at the next highest echelon of care. The Army’s FST operates in a similar manner.
In all this, the helicopter has become the de facto most important piece of military medical technology. But it must be the right helicopter, sized and equipped for the mission. And, the “snatch and go” method of scooping-up a wounded troop and whisking him or her off to receive care is not good enough. Today, the importance of dedicating assets specifically designed––from the ground up––to evacuate battlefield casualties is recognized widely and was explained by Colonel David Lam, senior U.S. Army medical officer assigned to the international military staff at NATO headquarters: “No longer will the empty truck or empty helicopter, without medical care of the highest level on board, be considered as providing an acceptable level of care.”
The aviators flying CASEVAC and MEDEVAC missions in OIF underscore the criticality of this mission. Writing in the Naval Helicopter Association’s professional journal, Rotor Review, a Navy pilot flying for the Army’s 2515th Air Ambulance Company put the stakes in dramatic terms:
“The 9-line call for launch came in at 1825, a little over one hour past sunset on a starlight only night. The mission was to pick up a wounded soldier at Navistar [Iraq/Kuwait border crossing station] and transport him to the Level III [surgical] care unit at Arifjan…The landing at Navistar revealed a young IED attack victim from Southern Iraq who had been transported from point of injury by ambulance for airlift. Ten minutes into the flight, the patient’s blood pressure dropped to 83 over 30 due to excessive bleeding from a lower extremity wound. The patient was failing.”
This dedication to deliver life-saving care from the air reveals a deeper issue at work and something that is part of the “DNA” of all those who wear the uniform. Lieutenant Commander Gary Keith, officer-in-charge of the Navy’s 2515th Navy Air Ambulance Detachments (NAAD) Detachment in Iraq, an operator who has seen first-hand the important role naval helicopter CASEVAC and MEDEVAC assets play, put it this way:
“The medical evacuation system cannot be moved into the periphery; it underwrites the all-volunteer force. Young sailors and Marines know that if they get injured, the Navy-Marine Corps team will return them as quickly as possible to the best medical care. This promise is how we have continued to sustain an all-volunteer force.”
Army, Navy, Air Force, Marine Corps and special operations pilots and aircrewmen have been making extraordinary efforts to save lives by transporting wounded warriors to higher echelons of care. But after six years of heroic efforts and oftentimes making do with aging, legacy equipment––and with the prospect of future battlefields mirroring those of Afghanistan and Iraq—the nation’s leadership must now take a hard look at the adequacy of its equipment on hand to deliver battlefield casualty care and ask the question: Is it reaching and saving every wounded warrior needing traumatic care in the golden hour?
More to the point, we must address the ways by which battlefield medical care is a precision weapon, delivered just in time to the wounded warrior at or near the point where he or she is injured? This would involve adapting the FST and FRSS mission into a “strike” concept with a full-up medical capability delivered by a rotary wing platform where it is needed, when it is needed and with the right capabilities on board, and also providing a robust enroute casualty care system (ERCS) to provide life support to the wounded warrior being delivered to a higher echelon of care for definitive surgery.
Unfortunately, current U.S. military helicopters are not up to the task. They are either too small, too large (representing overkill for the mission), or have unfortunate cabin configurations that do not facilitate proper patient enroute care. This is being increasingly recognized within the military medical community—and even in Congress. Referring to the multi-mission MH-60S, Representative Joseph Sestak, a member of the House Armed Services Committee and former Navy deputy chief of Naval Operations for Integration of Capabilities and Resources (N8) noted, “This little helicopter has neither the capacity in terms of lift or size or range to do several of these missions.”
A Road Ahead
While there are potential work-arounds that might make it possible to adapt current or planned Army, Navy, Marine Corps, Air Force or special operations rotary-wing or tilt-wing aircraft for the FST/FRSS-Strike/ERCS mission, military planners would be well-served if they conducted a no-holds-barred analysis of alternatives (AOA) to select a helicopter optimized for this highly specialized mission.
Finding such a platform need not be a decade-long process that begins with a clean-sheet design competition, as long as the Department of Defense is willing to look at the entire spectrum of available platforms, military and civilian, domestic and foreign. For example, helicopters classified in the medium-heavy category––such as the Sikorsky S-92 (civilian medium-lift category), Agusta-Westland US-101 (military medium-lift category) and EADS NH-90 (military medium-lift category), all with tens of thousands of flight hours in the field––might be “about right” for a capable FST/FRSS-Strike/ERCS aircraft.
However, it will take enlightened leadership to bring a new platform into military inventories, given the challenge of any “new start” program and the current DoD emphasis on “necking-down” the numbers of helicopter platforms that need to be supported. This desire is particularly acute as, increasingly, the department is being run as a business enterprise and business efficiencies oftentimes take center stage.
But business considerations must take a backseat to operational requirements, especially when that requirement means delivering on-scene and enroute care to wounded warriors on the battlefield. And given the enormous sums being spent by all the services on rotary-wing and tilt-wing aircraft over the Future Years Defense Plan (FYDP) and beyond, it is not at all clear if all the services pooled their aviation procurement dollars, they could field an affordable, medium-heavy, high-speed, FST/FRSS-Strike/ERCS platform that was optimized for Army, Navy, Air Force, Marine Corps and special operations needs.
Basic, back-of-the-envelope, math suggests that just a tiny percentage of the funds the military services intend to allocate to rotary-wing and tilt-wing aircraft during the next several decades, if invested in a five-service FST/FRSS-Strike/ERCS platform, could actually save the services scarce resources. This approach would be vastly superior to attempting to perform the mission in far-too-small and otherwise inadequate platforms, or trying to make due with far-too-large helicopters that are overkill for the mission and are enormously expensive to operate.
Military protective technology has evolved to the stage where our warriors can survive projectiles or bombs that would have killed them previously. Military medical technology has also evolved to the point where our wounded warriors can receive life-saving resuscitative care if that care is delivered on-scene, on-time. The challenge is to provide the right platform to deliver that care on-scene, on-time and to move that wounded warrior to a higher echelon of care without having his condition degrade. It is up to service planners to decide where they can fit one platform designed explicitly to rescue and revive our combat wounded in the Department of Defense’s $700 billion budget. ♦